Medical Review Board Meeting

On August 22-23, 2016, the Medical Review Board (MRB) met to deliberate on public comments from medical professionals and associations on the Federal Motor Carrier Safety Administration’s (FMCSA’s) and Federal Railroad Administration’s (FRA’s) Advanced Notice of Proposed Rulemaking (ANPRM) on obstructive sleep apnea.


The MRB’s task was to review and analyze all ANPRM comments and identify factors the Agency should consider regarding making a decision about the next step in the OSA rulemaking.
In addition to updating the recommendations the MRB first published in 2012, it also recommends that FMCSA ensure that all relevant stakeholders receive education regarding OSA symptoms, health consequences, risk factors, diagnosis, and treatment costs and benefits.
Educational resources should be specifically designed for Certified Medical Examiners (CMEs), drivers, and motor carriers.
The recommendations are submitted as a draft letter entitled “MRB Task 16-01 Report”

General Recommendations

  1. CMEs must screen drivers presenting for medical certification for OSA diagnostic testing
  2. CMEs cannot issue a medical card for more than 1 year to a driver with an established diagnosis of OSA, regardless of severity.
  3. A CME may certify a driver with an OSA diagnosis if the driver is being treated effectively
  4. For certification purposes, “effective treatment” or “treated effectively” is defined as the resolution of moderate to severe OSA to mild or better, as determined by a board-certified sleep specialist.

Immediate Disqualification

  1. Drivers should be disqualified immediately and referred for OSA diagnostic testing if any of the following conditions exist:
    1. Individuals who have admitted fatigue or sleepiness during the wake period.
    2. Individuals who have been involved in a sleep-related motor vehicle crash or accident or near crash.
  2. Drivers found non-compliant with treatment should be disqualified immediately until evaluated and treated effectively.
  3. The CME should have the discretion to disqualify any driver who appears to be at extremely high risk.
  4. Drivers disqualified for any of the above reasons must remain disqualified until evaluated and treated effectively.

Screening Criteria

The MRB recommends commercial drivers be referred for OSA diagnostic testing based on screening:

  1. Individuals with a BMI ≥ 40 mg/kg2.
    Mallampati Classification

    Mallampati Classification

  2. Individuals with a BMI ≥ 33 and < 40 mg/kg2 in addition to and at least 3 or more of the following:
    • Hypertension (treated or untreated);
    • Type 2 diabetes (treated or untreated);
    • History of stroke, coronary artery disease, or arrhythmias;
    • Micrognathia or retrognathia;
    • Loud snoring;
    • Witnessed apneas;
    • Small airway (Mallampati Classification of Class 3 or 4)
    • Neck size > 17 inches (male), 15.5 inches (female);
    • Hypothyroidism (untreated);
    • Age 42 and above; or
    • Male or post-menopausal female.

 

Other recommendations

The MRB also commented on conditional certification of a driver for 90 days while undergoing evaluation and treatment, frequency of testing and methods of diagnosis.
The diagnosis of sleep apnea should be made by a board certified sleep specialist.

Treatment

PAP is the preferred treatment, but the MRB makes recommendations for oral appliances and surgery.
 


Take the guesswork out of testing and management of drivers with sleep apnea

Sleep Apnea Management program


 

STOP BANG Screening for Sleep Apnea

For screening, I recommend the “STOP-BANG” method:

Snoring-loud, as in heard easily in the next room
Tiredness during the normal waking hours
Observed Apneas
Pressure = HTN
BMI >=35 (some would argue 33 is the right number)
Age >=50 (MRB changes this to >=42)
Neck Size > 17″ in males, 16″ in females (MRB changes this to 15.5 for females)
Gender – male or postmenopausal female.

The MRB adds to the criteria:
  • BMI >=40 – all get tested
  • BMI 33-39 + any 3 of the above or these criteria:
    • Diabetes
    • Stroke, Coronary Disease or Arrhythmia
    • Micrognathia or Retrognathia
    • Small Airway – Mallampati 3 or 4
    • Hypothyroidism (untreated)
and changes Age to >=42 from 50.

Get the Algorithm

 You can use the new recommended screening criteria in our algorithm, get it for free here:
OSA algoritm graphic
In our course we teach all the research available to date to give you confidence to assess and manage these drivers appropriately, including:
  • The impact obstructive sleep apnea has on large truck accidents, injuries and fatalities
  • How to use the right screening tools on every driver, every exam
  • How to order a sleep test, when to consider home sleep testing (HST) vs a polysomnography
  • Interpretation of the test in collaboration with a sleep specialist
  • How to determine when a driver needs treatment for sleep apnea
  • Recommended treatments
  • Certification or disqualification criteria and appropriate intervals
  • How to determine compliance with treatment and guide further certification/disqualfication
  • and more!

Managing Obstructive Sleep Apnea in Commercial Drivers

Read more about Sleep Apnea:
Every 17″ gets a Sleep Test
Screening For Sleep Apnea in DOT Physicals
When Your Specialist Won’t Commit
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